VIP Laptop Application

- C) Application (DNS)
- Received
- Outbound
- AT > Ord Notes
- AT > Ord Notes (2)
- UPS
- AT < Tracking #
- AT < Label Cost
- T4T Employee ID
  Leave this box blank
- Form ID*
- Generated ID*
- APPLICANTS WILL BE APPROVED ON A FIRST COME FIRST SERVE BASIS.
  
  The Veteran Improvement Program Laptop Application (VIPLA) is a resource made available to Veterans and their family that are in need.
  
  Each computer is certified by our technicians to be functioning. It has a technical assistance warranty for one (1) year and a 30-day limited warranty that covers parts and labor for repairs or replacement due to defects in workmanship or materials. We will pay for the return shipping during the 30-day warranty only. The warranties are conditional upon completion of the initial survey within two (2) weeks of receipt of the device. The IT support warranty is available through an online form link that is provided to approved applicants. The warranty and IT support have no recurring or additional costs. More on this toward the end of the application.
- VIP Laptop Application
  
  This application is intended to capture and prepare data as an application to request a laptop/desktop from Tech For Troops' Veteran Improvement Program.
  
  If you are preparing this application on behalf of someone else, you are referred to as the Preparer. The person the application is being prepared for is known as the recipient, applicant, or Veteran.
  
  Fields starting with "(PHI)" may contain sensitive information. These documents and information will be managed by Tech For Troops and not shared. Relevant Tech For Troops team members involved in the application review process may need to review documents to certify the application or eligibility.
  
  Tech For Troops reserves rights to edit, change, or delete this application at their discretion and without notice.
- Yes, Veteran Liaison preparerYes, Veteran family member preparerYes, other preparerNo. I am preparing this application for myself unassisted.
- Preparer Company, Organization, or Affiliation to applicant *
- Preparer Name*
  
  First NameLast Name
- Preparer Email*
  example@example.com
- Preparer Phone*
  Please enter a valid phone number.Format: (000) 000-0000.
- Preparer Phone Extension
- Preparer Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- T4T HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION, PERSONAL RECORDS, AND OTHER ELIGIBILITY DOCUMENTATION
  
  For use when such authorization is required.
- I, the Veteran recipient and applicant, authorize any aforementioned Application Preparer to use, disclose, and discuss my health information, personal records, and other eligibility documentation for purposes relating to this application. I, the veteran recipient and applicant, have read and agree to the following:
  
  I understand that documents may be uploaded and provided on my behalf to Tech For Troops. I understand that I have a right to revoke this authorization, in writing, at any time, prior to the submission of the application, and will be effective upon delivery to the application preparer in possession of my health information, personal records, and other eligibility documentation. I understand that uses and disclosures already made based upon my original permission cannot be taken back.
  
  I understand that it is possible that information used, disclosed, or discussed with my permission may be redisclosed by the recipient, Tech For Troops, to any party at the discretion of Tech For Troops, and is no longer protected by HIPAA Privacy Standards. Tech For Troops will not share, sell, or otherwise distribute information to marketing organizations, and all personally identifying information will be kept secure. I understand that these documents may be retained by Tech For Troops indefinitely. I understand that no annual review or follow-up regarding eligibility, approval status, or the application may take place.
  
  In order to receive a copy of this authorization, a request must be made in writing to the form owner, Tech For Troops. Contact information should be included. Requests may be submitted to the following address: Tech For Troops, ATTN: Disclosure Records, 4840 Waller Rd, Richmond, VA 23230. Upon receipt of the request, Tech For Troops will review the request and contact the individual submitting the request. Upon request validation and approval, Tech For Troops may disburse the records within 30 days.
- Veteran recipient name: Printed*
  
  First NameLast Name
- Veteran recipient & name: Signature*
  
  Clear
  This must be signed by the recipient, not the preparer. If needed, save the form and complete at a later time.
- (PHI) Other/Additional authorization for disclosure documents
  
  If you have been provided a separate form authorizing you to complete this application and release relevant documents, upload it here. At your discretion, additional authorization documentation may be submitted here. If your policies and procedures require a signature of the application recipient, contact T4T.
  Cancelof
- I am authorized (by the Veteran recipient) to complete this application. I understand that fraudulently submitting applications may result in application refusal and be punishable by law where applicable.
- Preparer Signature*
  
  Clear
  This must be signed by the individual preparing the application.
- Richmond VA T4T HQNewport News VA AreaNo
- Veteran Name*
  
  First NameLast Name
- Veteran Date of Birth*
  
  MonthDayYear
  Date
- Last Four of SSN*
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Veteran Home Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Email*
  example@example.com
- MaleFemaleOtherDecline to answer
- American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteDecline to answerOther
- Active DutyReserveNational GuardVietnam Era VeteranVeteranRetiredMilitary SpouseGold Star Family
- ArmyMarine CorpsNavyAir ForceCoast GuardSpace ForceArmy National GuardAir National GuardCivilian, Contractor, Non-MilitaryOther
- Start of service
- Combined years of service
- Photo Identification (must be in date, NOT expired)*
  
  The following forms of ID are accepted: State driver's license, State-issued identification card, Military-issued identification card, Valid U.S. Passport. ALL OTHER FORMS OF ID WILL NOT BE ACCEPTED.
  Cancelof
- (PHI) Military & Veteran Status Verification*
  
  Upload documentation proving military status. Ex: DD=214, NGB-22, Common Access Card (CAC), Driver's License with Veteran status, discharge papers, or other supporting documentation. ID Cards must not be expired.
  Cancelof
- All LAPTOPS issued to VIP recipients meet or exceed the following minimum standards:
  - Completely functional and free of defects or damages warrantied for 30-days
  - All keyboard characters visible and functioning
  - Built in speakers are functional and free of distortion
  - Webcam is functioning
  - Battery holds at least a 30 minute charge and is functioning
  - AC Adapter is provided
  - Mouse is provided
  - Windows 11 is activated
  - Minimum 256GB hard drive is included
  - Minimum of 8GB of RAM installed
  - Intel-based i5, i7, or equivalent processor
  Fulfilment of orders is based on our supplies on hand.
- All DESKTOPS issued to VIP recipients meet or exceed the following minimum standards:
  - Completely functional and free of defects or damages
  - All keyboard characters visible and functioning
  - Mouse is provided
  - 18" Monitor is provided
  - Webcam is attached or provided and functioning
  - Windows 10 is activated
  - Minimum 1TB hard drive is included
  - Minimum of 4GB of RAM installed
  - Intel-based i5, i7, or equivalent processor
  We are currently unable to supply speakers.
  
  Fulfilment of orders is based on our supplies on hand.
- LaptopDesktop
- Through this resource, you may apply for a scholarship toward the purchase of a refurbished computer provided by Tech For Troops.
  
  The scholarship does not cover 100% of the costs associated with receiving a computer.
- Applicant Scholarship Eligibility
  
  To qualify for a scholarship, applicants must prove that they are below the 200% poverty level. Applicants exceeding 200% and those with a VA Disability rating are still encouraged to apply and provide supporting eligibility documentation. All applicants have the opportunity to provide supporting documentation at their discretion. Scholarship amounts may vary and are awarded in various amounts at the discretion of Tech For Troops.
- By submitting supporting documentation, applicants may receive a scholarship toward the purchase of a laptop computer. Scholarship amounts may vary throughout the year based on scholarship funds available and on-hand inventory. There is no guarantee an application will be accepted.
  
  Required Documents
  A photo ID is required. Supporting documentation must include the applicant's name and a date within the past 6 months of the application unless it is an annual document such as a tax return.
  
  EBT cards, Medicaid cards outside of the current coverage year, and pay stubs are not acceptable documents.
  
  Accepted Eligibility Documents
  We require a document showing enrollment in an income-based government assistance program. All proof of eligibility must be dated within the last 6 months (unless it is an annual document, like a tax return), and include the recipient's name printed on the proof.
  
  Some programs that provide eligibility are:*
  - Adult & Child Mental Health Case Management*
  - Employment Services*
  - Extended Foster Care
  - Food Support (a dated letter showing current eligibility is required)
  - Financial Assistance, such as GA, TANF, etc. (a dated letter showing current eligibility is required)
  - Head Start
  - Low-Income Home Energy Assistance Program (LIHEAP)
  - Medicaid or Medical Assistance (provide a document that says "MA" or "Medical Assistance" on it)
  - The National School Lunch Program's Free or Reduced Lunch Program
  - Section 8, Federal Public Housing Assistance, or Group Residential Housing (GRH)
  - Social Security Disability (SSD)
  - Supplemental Security Income (SSI)*
  - A Statement of benefits from Social Security, General Assistance, Veteran
  - Administration, Retirement/Pension or Unemployment Benefits
  - Pell Grant
    Note: Medicare documents alone are not accepted.
  For households that qualify under the net income test (200% poverty level), the following documentation will be accepted as part of the application process:*
  - The prior year's state, federal, or tribal tax return (W2 forms or pay stubs are not acceptable)
  - A Social Security statement of benefits*
  - A Veteran Administration statement of benefits*
  - A retirement/pension statement of benefits*
  - An Unemployment/Workmen's Compensation statement of benefits*
  - Federal or tribal notice letter of participation in General Assistance
  - A divorce decree, child support court document, or other official documents
  *Any proof of eligibility is subject to approval by Tech For Troops staff. Additional documents may be required to unquestioningly prove income or enrollment in government assistance program. Eligibility approval for online orders may take up to 5 business days.
- Number of persons in family: *
- Annual family income: *
- (PHI) Eligibility & Supporting Documents*
  
  Ensure your name is clearly visible on the supporting documents. Where applicable, a date should also be visible.
  Cancelof
- (PHI) Eligibility & Supporting comments or notes
- YesNoNo housing/homelessOther
- Shipping Address (PO Box addresses are NOT accepted)*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- PreparerVeteranOther
- Email invoice to: *
  example@example.com
- Approval not guaranteed
  
  Submission of an application does not guarantee a laptop or approval. Once the application has been reviewed, you will be notified. Prior to purchase, a quote for pricing will be provided. Payment will be fulfilled online via invoice. Applicants receiving a scholarship will receive reduced pricing up to 80% of the cost associated with the device(s). Scholarship recipients subject to additional terms and conditions. If an application is incomplete or payment is not received in a timely manner, fulfillment may be delayed or declined.
  
  I understand and agree by initialing below:
- Initials*
- Warranty & Service
  
  This device has a technical assistance warranty by Tech For Troops at no additional cost for 1 year. It also has a 30-day limited warranty that covers parts and labor for repairs or replacement due to defects in workmanship or materials. We will pay for the return shipping during the 30-day warranty. **The initial survey must be completed within two (2) weeks of receipt in order to start the warranty.** The information to complete the survey is provided in the paperwork included with your device. Tech For Troops reserves the right to cancel, void, replace, reinstate, or otherwise alter all warranty coverages at any time. We do not provide support for third-party software.
  
  If a replacement is required after 30 days, return shipping fees are the responsibility of the Veteran.
  
  ·         If a device is damaged due to negligence, such as liquid or water damage, intentional physical destruction, and so on, you will be charged the original purchase price for a replacement.
  
  ·         Theft (police report required) and fire (fire or insurance report required) are eligible for replacement at no cost. There is a one (1) replacement limit.
  
  ·         We test battery quality in all refurbished laptops. The battery is guaranteed to hold a charge for at least 30 minutes during the 30-day warranty period. The battery is not covered past 30 days. The cost to install new batteries is prohibitive for our non-profit organization.
  
  If our laptops do not meet your needs, we encourage you to explore additional options on eBay or Amazon.
  
  The T4T barcode number sticker, located on the bottom, must remain on the laptop. DO NOT REMOVE IT.
  
  I understand and agree by initialing below:
- Initials*
- Malfunction
  
  Tech For Troops is not responsible for any injury sustained through the use, or misuse, of the devices provided.
  
  I understand and agree by initialing below:
- Initials*
- Media release
  
  I hereby authorize Tech For Troops to publish photographs, videos, interviews, or other forms of media, taken of me for use in Tech For Troops print, digital, online, and video-based marketing materials, as well as other Company publications. I hereby release and hold harmless Tech For Troops from any reasonable expectation of privacy or confidentiality associated with the media specified above. I further acknowledge that since my participation in publications and websites produced by Tech For Troops is voluntary, I will receive no financial compensation. I further agree that my participation in any marketing materials, social media and website produced by Tech For Troops confers upon me no rights of ownership or royalties whatsoever. I hereby release Tech For Troops, it’s volunteers, third parties and its employees involved in the creation of marketing materials from liability for any claims by me or any third party in connection with my participation.
  
  I understand and agree by initialing below:
- YesNo, I do not want to participate in voluntary marketing materials
- Initials*
- I have read and understand all items in this application, and certify that they are completed accurately to the best of my ability. *
  
  Clear
- Applicant Survey Questions
  
  These questions are used solely for analytical purposes, and are submitted anonymously. The answers provided do not influence any decision making regarding scholarships, pricing, or other terms. Please answer honestly.
- YesNo
- YesNo
- YesNo
- YesNo
- HomeWorkCafeOther
- Yes, flip phoneYes, smart phoneNo
- High SchoolGEDSome CollegeCollege (2 year degree)College (4 year degree)None
- YesNo
- Not employed, not seeking employmentNot employed, seeking employmentEmployed, not seeking new employmentEmployed, seeking new employment
- YesNo
- YesNo
- What do you hope to learn about computers?*
- Yes, opt inNo, thank you!No, already signed up!
- How satisfied are you with the application process?*
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is Worst, 5 is Best
- Additional feedback
- Please verify that you are human:*
- Click print (save as PDF) as a backup copy of your application, then click submit.
  
  If you do not receive a "Thank You" after hitting submit, please look at the top of the application to determine your errors. Once corrected, please click submit again.
  
  You will receive a confirmation email. If you do not receive a confirmation email, contact us at vipla@techfortroops.org
- Should be Empty:

T4T HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION, PERSONAL RECORDS, AND OTHER ELIGIBILITY DOCUMENTATION

Applicant Scholarship Eligibility

Applicant Survey Questions